臺灣核心實作指引(TW Core IG)
0.1.1 - Trial Use

This page is part of the 臺灣核心實作指引(TW Core IG) (v0.1.1: Releases) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: TWCoreCondition - Detailed Descriptions

Active as of 2023-08-30

Definitions for the Condition-twcore resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Condition
Definition

一個臨床病情、問題、診斷或其他事件、情況、或臨床概念,已上升到需要關注的程度。

Short有關病情、問題或診斷的詳細資訊
2. Condition.id
Definition

resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。

Short不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。
Comments

一個resource使用新增操作(create operation)提交給伺服器時是此resource唯一沒有id的時刻

4. Condition.meta
Definition

關於resource的metadata。這是由基礎建設維護的內容。對內容的改變可能並不總是與resource的版本改變相關。

Short此Condition Resource的metadata
6. Condition.implicitRules
Definition

構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是IG定義特殊規則及其他profiles的參照。

Short創建此內容所依據的一組規則
Comments

宣告這套規則限制了內容只能被有限的貿易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和(或)規範編寫者應該避免使用這個資料項目。通常,在使用時,此URL是對實作指引的參照,此指引將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。

8. Condition.language
Definition

編寫此resource的基礎語言

Short用以表述Condition Resource內容的語言
Comments

提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此基礎語言。不應該假定Resource.language自動適用於敘述。如果指定語言,它也應該被指定在html中的div元素(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。

BindingThe codes SHOULD be taken from CommonLanguages: 人類語言;鼓勵使用CommonLanguages值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。
Additional BindingsPurpose
AllLanguagesMax Binding
Example<br/><b>Value</b>:zh-TW
10. Condition.text
Definition

人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義可定義哪些內容應該在敘述中表示,以確保臨床安全。

ShortCondition Resource之內容摘要以供人閱讀
Comments

內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。在某些情況下,resource可能只有文字表述,很少或沒有額外的離散資料(只要滿足所有minOccurs=1的資料項目)。這對於來自舊有系統的資料可能是必要的,在這些系統中,從 「文字表述區塊(text blob) 」獲取訊息,或者文字表述是額外的原始輸入或敘述,而編碼訊息是後來添加的。

Must Supporttrue
12. Condition.contained
Definition

這些resource內嵌(contains)的resource不會另外存於任何FHIR伺服器,意即它們無法在任何FHIR伺服器中被找到,也無法有自己獨立的資料異動/交易(transaction)範圍。

Short內嵌的(contained)、行內的Resources
Comments

內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。在某些情況下,resource可能只有文字表述,很少或沒有額外的離散資料(只要滿足所有minOccurs=1的資料項目)。這對於來自舊有系統的資料可能是必要的,在這些系統中,從 「文字表述區塊(text blob) 」獲取訊息,或者文字表述是額外的原始輸入或敘述,而編碼訊息是後來添加的。

14. Condition.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

16. Condition.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。
修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互操作性。更多訊息,請參見修飾用的資料項目擴充之定義

18. Condition.identifier
Definition

由執行者或其他系統指定給此病情、問題或診斷的業務用識別碼,即使此resource作更新及在伺服器之間的傳遞,此識別碼仍保持不變。

Short此病情、問題或診斷的外部識別碼
Comments

這是一個業務識別碼,不是一個resource識別碼(詳見討論)。最好的做法是該識別碼只出現在單個resource實例上,但是業務實務有可能會規定可以在多個resource實例中具有相同識別碼—甚至可能具有不同的resource型例。例如:多個 「Patient(病人)」和 「Person(個人)」resource實例可能共用同一個社會保險號碼。

NoteThis is a business identifier, not a resource identifier (see discussion)
Requirements

允許識別各參與系統所知的此病情、問題或診斷資訊,並在各伺服器之間保持一致的方式。

20. Condition.clinicalStatus
Definition

此病情、問題或診斷的臨床狀態

Comments

data type是CodeableConcept,因為clinicalStatus涉及到一些臨床判斷,例如:可能需要比所需的FHIR值集更多的特殊性。例如:SNOMED編碼可能允許更多的特殊性。

Control1..?
BindingThe codes SHALL be taken from ConditionClinicalStatusCodes: 病情、問題或診斷的臨床狀態;應填入ConditionClinicalStatusCodes值集中的其中一個代碼。
TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
22. Condition.verificationStatus
Definition

支持此病情、問題或診斷的臨床狀態之驗證狀態

Comments

verificationStatus不是必須的。例如:當病人在急診室出現腹痛時,不可能出現驗證狀態。資料類型是CodeableConcept,因為verificationStatus涉及到一些臨床判斷,因此可能需要比所需的FHIR值集更多的特殊性。例如:SNOMED編碼可能允許更多的特殊性。

BindingThe codes SHALL be taken from ConditionVerificationStatus: 支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態;應填入ConditionVerificationStatus值集中的其中一個代碼。
TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
24. Condition.category
Definition

指定此病情、問題或診斷的類別

Comments

這種分類往往具有很強的情境性,在其他情境下可能顯得區分度不高,或沒有什麼用處。

Control1..1
BindingUnless not suitable, these codes SHALL be taken from ConditionCategoryCodes: 指定病情、問題或診斷的類別;應填入ConditionCategoryCodes值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。
TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
26. Condition.severity
Definition

臨床醫生對病情、問題或診斷嚴重程度的主觀評估

Short病情、問題或診斷的主觀嚴重程度
Comments

如有可能,最好用專門術語對嚴重程度進行編碼。

BindingThe codes SHOULD be taken from Problem Severity - IPS: 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;鼓勵使用Problem Severity - IPS值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。
TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
28. Condition.code
Definition

病情、問題或診斷的識別

Short病情、問題或診斷的識別
BindingFor example codes, see Condition/Problem/DiagnosisCodes: 病情、問題或診斷的識別;可參考Condition/Problem/DiagnosisCodes值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。
TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
Requirements

0..1,主要用於說明敘述性resource。

30. Condition.code.extension
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

32. Condition.code.coding
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

SlicingThis element introduces a set of slices on Condition.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ $this
34. Condition.code.coding:icd10-cm-2021
Slice Nameicd10-cm-2021
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
BindingThe codes SHALL be taken from 臺灣2021年中文版ICD-10-CM值集: 病情、問題或診斷的識別;應填入臺灣2021年中文版ICD-10-CM值集值集中的其中一個代碼。
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

36. Condition.code.coding:icd10-cm-2014
Slice Nameicd10-cm-2014
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
BindingThe codes SHALL be taken from 臺灣2014年中文版ICD-10-CM值集: 病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-CM值集值集中的其中一個代碼。
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

38. Condition.code.coding:icd9-cm-2001
Slice Nameicd9-cm-2001
Control0..1
BindingThe codes SHALL be taken from 臺灣2001年中文版ICD-9-CM值集
Must Supporttrue
40. Condition.code.coding:absentOrUnknownProblem
Slice NameabsentOrUnknownProblem
Definition

表示「absent problem」或「problems unknown」的代碼

Short不存在的問題或未知問題的代碼
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
BindingThe codes SHALL be taken from Absent or Unknown Problems - IPS: 應填入Absent or Unknown Problems - IPS值集中的其中一個代碼。
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

42. Condition.code.coding:sct
Slice Namesct
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
BindingThe codes SHALL be taken from SNOMED CT診斷代碼值集: 應填入SNOMED CT診斷代碼值集值集中的其中一個代碼。
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

44. Condition.bodySite
Definition

此病情、問題或診斷表現出來的解剖位置

Short如果相關請填寫解剖位置
Comments

只有在Condition.code中找到的代碼未隱含此資料項目概念時才使用。如果使用案例(use-case)要求將BodySite作為一個單獨的resource來處理(例如:識別和追踪),那麼就使用標準的資料項目擴充方式來擴充bodySite。可以是一個摘要代碼,也可以是對一個非常精確位置定義的參照,或者兩者都是。

BindingFor example codes, see SNOMEDCTBodyStructures: 描述解剖位置的代碼。可包括側面;可參考SNOMEDCTBodyStructures值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。
TypeCodeableConcept(TW CodeableConcept)
Must Supporttrue
46. Condition.subject
Definition

表示與此病情、問題或診斷紀錄相關的病人或實體集合(Group resource)

Short誰有此病情、問題或診斷?
TypeReference(TW Core Patient, Group)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Requirements

實體集合(Group resource)通常用於獸醫或公共衛生的案例

48. Condition.encounter
Definition

此病情、問題或診斷記載在哪次的「就醫(Encounter)」紀錄或者與此病情、問題或診斷紀錄密切相關的「就醫(Encounter)」紀錄

Short作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄
Comments

通常是此病情、問題或診斷發生的就醫事件,雖然有些活動可能在就醫結束之前或之後開始,但仍與就醫事件的情境有關。這筆紀錄表明與此病情、問題或診斷紀錄相關的就醫事件(Encounter)。「新的」診斷的情況下,反映病情、問題或診斷的持續/修訂資訊可能與首次就醫所知道的病情、問題或診斷不同。

TypeReference(TW Core Encounter)
50. Condition.onset[x]
Definition

醫師認為此病情、問題或診斷之推估或實際發生時間或日期時間等

Short估計的或實際的日期、日期—時間或年齡。
Comments

onsetAge通常是指病人說明病情何時開始發生的年齡

TypeChoice of: dateTime, Age, Period, Range, string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesdateTime
52. Condition.abatement[x]
Definition

病情、問題或診斷緩解或開始緩解的日期或估計日期。因為與「緩解(remissio)」或 「解決(resolution)」相關的許多過多含義—病情、問題或診斷不會真正解決,但它們可以緩解,所以稱為「緩解 (abatement)」,

Short何時解決/緩解
Comments

解決(resolution)和緩解(remission)之間沒有明確的區別,因為在許多情況下,兩者的區別並不明顯。當病人說明病情、問題或診斷緩解的年齡時,一般使用onsetAge。如果沒有abatement這個資料項目,就不知道狀況是否已經解決或緩解;應用程式和使用者一般應假定病情、問題或診斷仍存在。當abatementString存在時,它意味著病情、問題或診斷已緩解。

TypeChoice of: dateTime, Age, Period, Range, string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesdateTime
54. Condition.recordedDate
Definition

recordedDate表述此Condition記錄何時於系統中建立,這通常是系統產生的日期。

Short記錄的日期
56. Condition.recorder
Definition

記錄病情、問題或診斷內容並對其內容負責的個人

Short誰記錄此病情、問題或診斷
TypeReference(TW Core Practitioner, PractitionerRole, TW Core Patient, RelatedPerson)
58. Condition.asserter
Definition

提出此病情、問題或診斷說明的人

Short聲稱有此病情、問題或診斷的人
TypeReference(TW Core Practitioner, PractitionerRole, TW Core Patient, RelatedPerson)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
60. Condition.stage
Definition

病情、問題或診斷的臨床分期或分級,可能包括正式的嚴重程度評估。

Short分期(stage)/分級(grade),通常是正式的評估。
62. Condition.stage.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
64. Condition.stage.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

66. Condition.stage.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。
修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互操作性。更多訊息,請參見修飾用的資料項目擴充之定義

68. Condition.stage.summary
Definition

對分期的簡單摘要,如「第3期」。針對特定疾病的分期測定。

Short簡單的摘要(特定疾病)。
BindingFor example codes, see ConditionStage: 描述病情、問題或診斷分期的代碼(例如:癌症分期)。可參考ConditionStage值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。
TypeCodeableConcept(TW CodeableConcept)
70. Condition.stage.assessment
Definition

分期評估所依據的證據之正式記錄

Short正式的評估記錄
TypeReference(ClinicalImpression, DiagnosticReport, TW Core Observation Laboratory Result, TW Core Observation Vital Signs)
72. Condition.stage.type
Definition

分期的種類,如病理分期或臨床分期。

Short分期的種類
BindingFor example codes, see ConditionStageType: 病情、問題或診斷分期種類的代碼(如臨床或病理);可參考ConditionStageType值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。
TypeCodeableConcept(TW CodeableConcept)
74. Condition.evidence
Definition

作為病情、問題或診斷驗證狀態基礎的支持證據/臨床表現,如證實或反駁病情、問題或診斷的證據。

Short支持的證據
Comments

證據可以是一個簡單的編碼症狀/臨床表現的清單,或參考檢驗檢查或者正式評估,或者兩者都是。

76. Condition.evidence.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
78. Condition.evidence.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

80. Condition.evidence.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。
修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互操作性。更多訊息,請參見修飾用的資料項目擴充之定義

82. Condition.evidence.code
Definition

導致記錄此病情、問題或診斷的表現或症狀

Short表現/症狀
BindingFor example codes, see ManifestationAndSymptomCodes: 病情、問題或診斷的表現或症狀之代碼;可參考ManifestationAndSymptomCodes值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。
TypeCodeableConcept(TW CodeableConcept)
84. Condition.evidence.detail
Definition

其他相關資訊的連接,包括病理報告。

Short在其他地方找到的支持資訊
86. Condition.note
Definition

關於此Condition的附加資訊。這是一個一般的註釋/意見紀錄,用於描述病情、問題或診斷、其診斷和預後。

Short關於此Condition的附加資訊
Must Supporttrue

Guidance on how to interpret the contents of this table can be found here

0. Condition
Definition

一個臨床病情、問題、診斷或其他事件、情況、或臨床概念,已上升到需要關注的程度。


A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

Short有關病情、問題或診斷的詳細資訊Detailed information about conditions, problems or diagnoses
Control0..*
Is Modifierfalse
Summaryfalse
Invariantscon-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item (clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty())
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists())
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error (verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty())
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item (clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty())
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists())
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error (verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty())
2. Condition.id
Definition

resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。


The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Short不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。Logical id of this artifact
Comments

一個resource使用新增操作(create operation)提交給伺服器時是此resource唯一沒有id的時刻


The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control0..1
Typeidstring
Is Modifierfalse
Summarytrue
4. Condition.meta
Definition

關於resource的metadata。這是由基礎建設維護的內容。對內容的改變可能並不總是與resource的版本改變相關。


The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Short此Condition Resource的metadataMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. Condition.implicitRules
Definition

構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是IG定義特殊規則及其他profiles的參照。


A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Short創建此內容所依據的一組規則A set of rules under which this content was created
Comments

宣告這套規則限制了內容只能被有限的貿易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和(或)規範編寫者應該避免使用這個資料項目。通常,在使用時,此URL是對實作指引的參照,此指引將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。


Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Condition.language
Definition

編寫此resource的基礎語言


The base language in which the resource is written.

Short用以表述Condition Resource內容的語言Language of the resource content
Comments

提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此基礎語言。不應該假定Resource.language自動適用於敘述。如果指定語言,它也應該被指定在html中的div元素(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。


Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguageshttp://hl7.org/fhir/ValueSet/languages

人類語言;鼓勵使用CommonLanguages值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。


A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Example<br/><b>Value</b>:zh-TW
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Condition.text
Definition

人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義可定義哪些內容應該在敘述中表示,以確保臨床安全。


A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

ShortCondition Resource之內容摘要以供人閱讀Text summary of the resource, for human interpretation
Comments

內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。在某些情況下,resource可能只有文字表述,很少或沒有額外的離散資料(只要滿足所有minOccurs=1的資料項目)。這對於來自舊有系統的資料可能是必要的,在這些系統中,從 「文字表述區塊(text blob) 」獲取訊息,或者文字表述是額外的原始輸入或敘述,而編碼訊息是後來添加的。


Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Must Supporttrue
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Condition.contained
Definition

這些resource內嵌(contains)的resource不會另外存於任何FHIR伺服器,意即它們無法在任何FHIR伺服器中被找到,也無法有自己獨立的資料異動/交易(transaction)範圍。


These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Short內嵌的(contained)、行內的ResourcesContained, inline Resources
Comments

內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。在某些情況下,resource可能只有文字表述,很少或沒有額外的離散資料(只要滿足所有minOccurs=1的資料項目)。這對於來自舊有系統的資料可能是必要的,在這些系統中,從 「文字表述區塊(text blob) 」獲取訊息,或者文字表述是額外的原始輸入或敘述,而編碼訊息是後來添加的。


This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. Condition.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。


May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Short擴充的資料項目Additional content defined by implementations
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
16. Condition.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。
修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。


May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。Extensions that cannot be ignored
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互操作性。更多訊息,請參見修飾用的資料項目擴充之定義


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
18. Condition.identifier
Definition

由執行者或其他系統指定給此病情、問題或診斷的業務用識別碼,即使此resource作更新及在伺服器之間的傳遞,此識別碼仍保持不變。


Business identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

Short此病情、問題或診斷的外部識別碼External Ids for this condition
Comments

這是一個業務識別碼,不是一個resource識別碼(詳見討論)。最好的做法是該識別碼只出現在單個resource實例上,但是業務實務有可能會規定可以在多個resource實例中具有相同識別碼—甚至可能具有不同的resource型例。例如:多個 「Patient(病人)」和 「Person(個人)」resource實例可能共用同一個社會保險號碼。


This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Summarytrue
Requirements

允許識別各參與系統所知的此病情、問題或診斷資訊,並在各伺服器之間保持一致的方式。


Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Condition.clinicalStatus
Definition

此病情、問題或診斷的臨床狀態


The clinical status of the condition.

Short概念(Concept)— 參照一個專門術語或只是文字表述active | recurrence | relapse | inactive | remission | resolved
Comments

data type是CodeableConcept,因為clinicalStatus涉及到一些臨床判斷,例如:可能需要比所需的FHIR值集更多的特殊性。例如:SNOMED編碼可能允許更多的特殊性。


The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

Control10..1
This element is affected by the following invariants: ele-1, con-3, con-4, con-5
BindingThe codes SHALL be taken from ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1

病情、問題或診斷的臨床狀態;應填入ConditionClinicalStatusCodes值集中的其中一個代碼。


The clinical status of the condition or diagnosis.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalsetrue because This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. Condition.verificationStatus
Definition

支持此病情、問題或診斷的臨床狀態之驗證狀態


The verification status to support the clinical status of the condition.

Short概念(Concept)— 參照一個專門術語或只是文字表述unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Comments

verificationStatus不是必須的。例如:當病人在急診室出現腹痛時,不可能出現驗證狀態。資料類型是CodeableConcept,因為verificationStatus涉及到一些臨床判斷,因此可能需要比所需的FHIR值集更多的特殊性。例如:SNOMED編碼可能允許更多的特殊性。


verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

Control0..1
This element is affected by the following invariants: ele-1, con-3, con-5
BindingThe codes SHALL be taken from ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1

支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態;應填入ConditionVerificationStatus值集中的其中一個代碼。


The verification status to support or decline the clinical status of the condition or diagnosis.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalsetrue because This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Condition.category
Definition

指定此病情、問題或診斷的類別


A category assigned to the condition.

Short概念(Concept)— 參照一個專門術語或只是文字表述problem-list-item | encounter-diagnosis
Comments

這種分類往往具有很強的情境性,在其他情境下可能顯得區分度不高,或沒有什麼用處。


The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.

Control10..1*
This element is affected by the following invariants: ele-1
BindingUnless not suitable, these codes SHALL be taken from ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category

指定病情、問題或診斷的類別;應填入ConditionCategoryCodes值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。


A category assigned to the condition.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. Condition.severity
Definition

臨床醫生對病情、問題或診斷嚴重程度的主觀評估


A subjective assessment of the severity of the condition as evaluated by the clinician.

Short病情、問題或診斷的主觀嚴重程度Subjective severity of condition
Comments

如有可能,最好用專門術語對嚴重程度進行編碼。


Coding of the severity with a terminology is preferred, where possible.

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHOULD be taken from Problem Severity - IPShttp://hl7.org/fhir/ValueSet/condition-severity

臨床醫生對病情、問題或診斷嚴重程度的主觀評價;鼓勵使用Problem Severity - IPS值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。


A subjective assessment of the severity of the condition as evaluated by the clinician.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Condition.code
Definition

病情、問題或診斷的識別


Identification of the condition, problem or diagnosis.

Short病情、問題或診斷的識別Identification of the condition, problem or diagnosis
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code

病情、問題或診斷的識別;可參考Condition/Problem/DiagnosisCodes值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。


Identification of the condition or diagnosis.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Requirements

0..1,主要用於說明敘述性resource。


0..1 to account for primarily narrative only resources.

Alternate Namestype
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Condition.code.extension
Definition

An Extension


May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortExtensionAdditional content defined by implementations
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Condition.code.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ url
32. Condition.code.coding
Definition

由專門術語系統(terminology system)所定義之代碼的參照。


A reference to a code defined by a terminology system.

Short由專門術語系統(terminology system)定義的代碼Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..*
This element is affected by the following invariants: ele-1
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Condition.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ $this
34. Condition.code.coding:icd10-cm-2021
Slice Nameicd10-cm-2021
Definition

由專門術語系統(terminology system)所定義之代碼的參照。


A reference to a code defined by a terminology system.

Short此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..1*
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from For codes, see 臺灣2021年中文版ICD-10-CM值集: 病情、問題或診斷的識別;應填入臺灣2021年中文版ICD-10-CM值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. Condition.code.coding:icd10-cm-2014
Slice Nameicd10-cm-2014
Definition

由專門術語系統(terminology system)所定義之代碼的參照。


A reference to a code defined by a terminology system.

Short此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..1*
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from For codes, see 臺灣2014年中文版ICD-10-CM值集: 病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-CM值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. Condition.code.coding:icd9-cm-2001
Slice Nameicd9-cm-2001
Definition

由專門術語系統(terminology system)所定義之代碼的參照


A reference to a code defined by a terminology system.

Short由專門術語系統(terminology system)定義的代碼Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..1*
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from For codes, see 臺灣2001年中文版ICD-9-CM值集
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. Condition.code.coding:absentOrUnknownProblem
Slice NameabsentOrUnknownProblem
Definition

表示「absent problem」或「problems unknown」的代碼


A reference to a code defined by a terminology system.

Short不存在的問題或未知問題的代碼Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..1*
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from For codes, see Absent or Unknown Problems - IPS: 應填入Absent or Unknown Problems - IPS值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. Condition.code.coding:sct
Slice Namesct
Definition

由專門術語系統(terminology system)所定義之代碼的參照。


A reference to a code defined by a terminology system.

Short此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。Code defined by a terminology system
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。


Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control0..1*
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from For codes, see SNOMED CT診斷代碼值集: 應填入SNOMED CT診斷代碼值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼


Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. Condition.code.text
Definition

輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。


A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Short概念的文字表示法Plain text representation of the concept
Comments

很多時候,此文字表述與其中一個代碼的顯示名稱相同。


Very often the text is the same as a displayName of one of the codings.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。


The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. Condition.bodySite
Definition

此病情、問題或診斷表現出來的解剖位置


The anatomical location where this condition manifests itself.

Short如果相關請填寫解剖位置Anatomical location, if relevant
Comments

只有在Condition.code中找到的代碼未隱含此資料項目概念時才使用。如果使用案例(use-case)要求將BodySite作為一個單獨的resource來處理(例如:識別和追踪),那麼就使用標準的資料項目擴充方式來擴充bodySite。可以是一個摘要代碼,也可以是對一個非常精確位置定義的參照,或者兩者都是。


Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension bodySite. May be a summary code, or a reference to a very precise definition of the location, or both.

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site

描述解剖位置的代碼。可包括側面;可參考SNOMEDCTBodyStructures值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。


Codes describing anatomical locations. May include laterality.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. Condition.subject
Definition

表示與此病情、問題或診斷紀錄相關的病人或實體集合(Group resource)


Indicates the patient or group who the condition record is associated with.

Short誰有此病情、問題或診斷?Who has the condition?
Control1..1
TypeReference(TW Core Patient, Group, Patient)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Requirements

實體集合(Group resource)通常用於獸醫或公共衛生的案例


Group is typically used for veterinary or public health use cases.

Alternate Namespatient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Condition.encounter
Definition

此病情、問題或診斷記載在哪次的「就醫(Encounter)」紀錄或者與此病情、問題或診斷紀錄密切相關的「就醫(Encounter)」紀錄


The Encounter during which this Condition was created or to which the creation of this record is tightly associated.

Short作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄Encounter created as part of
Comments

通常是此病情、問題或診斷發生的就醫事件,雖然有些活動可能在就醫結束之前或之後開始,但仍與就醫事件的情境有關。這筆紀錄表明與此病情、問題或診斷紀錄相關的就醫事件(Encounter)。「新的」診斷的情況下,反映病情、問題或診斷的持續/修訂資訊可能與首次就醫所知道的病情、問題或診斷不同。


This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".

Control0..1
TypeReference(TW Core Encounter, Encounter)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Condition.onset[x]
Definition

醫師認為此病情、問題或診斷之推估或實際發生時間或日期時間等


Estimated or actual date or date-time the condition began, in the opinion of the clinician.

Short估計的或實際的日期、日期—時間或年齡。Estimated or actual date, date-time, or age
Comments

onsetAge通常是指病人說明病情何時開始發生的年齡


Age is generally used when the patient reports an age at which the Condition began to occur.

Control0..1
TypeChoice of: dateTime, Age, Period, Range, string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesdateTime
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Condition.abatement[x]
Definition

病情、問題或診斷緩解或開始緩解的日期或估計日期。因為與「緩解(remissio)」或 「解決(resolution)」相關的許多過多含義—病情、問題或診斷不會真正解決,但它們可以緩解,所以稱為「緩解 (abatement)」,


The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate.

Short何時解決/緩解When in resolution/remission
Comments

解決(resolution)和緩解(remission)之間沒有明確的區別,因為在許多情況下,兩者的區別並不明顯。當病人說明病情、問題或診斷緩解的年齡時,一般使用onsetAge。如果沒有abatement這個資料項目,就不知道狀況是否已經解決或緩解;應用程式和使用者一般應假定病情、問題或診斷仍存在。當abatementString存在時,它意味著病情、問題或診斷已緩解。


There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.

Control0..1
This element is affected by the following invariants: con-4
TypeChoice of: dateTime, Age, Period, Range, string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesdateTime
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Condition.recordedDate
Definition

recordedDate表述此Condition記錄何時於系統中建立,這通常是系統產生的日期。


The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.

Short記錄的日期Date record was first recorded
Control0..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. Condition.recorder
Definition

記錄病情、問題或診斷內容並對其內容負責的個人


Individual who recorded the record and takes responsibility for its content.

Short誰記錄此病情、問題或診斷Who recorded the condition
Control0..1
TypeReference(TW Core Practitioner, PractitionerRole, TW Core Patient, RelatedPerson, Practitioner, Patient)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. Condition.asserter
Definition

提出此病情、問題或診斷說明的人


Individual who is making the condition statement.

Short聲稱有此病情、問題或診斷的人Person who asserts this condition
Control0..1
TypeReference(TW Core Practitioner, PractitionerRole, TW Core Patient, RelatedPerson, Practitioner, Patient)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. Condition.stage
Definition

病情、問題或診斷的臨床分期或分級,可能包括正式的嚴重程度評估。


Clinical stage or grade of a condition. May include formal severity assessments.

Short分期(stage)/分級(grade),通常是正式的評估。Stage/grade, usually assessed formally
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscon-1: Stage SHALL have summary or assessment (summary.exists() or assessment.exists())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
con-1: Stage SHALL have summary or assessment (summary.exists() or assessment.exists())
64. Condition.stage.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。


Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short唯一可識別ID,以供資料項目間相互參照。Unique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
66. Condition.stage.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。


May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Short擴充的資料項目Additional content defined by implementations
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
68. Condition.stage.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。
修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。


May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。Extensions that cannot be ignored even if unrecognized
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互操作性。更多訊息,請參見修飾用的資料項目擴充之定義


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
70. Condition.stage.summary
Definition

對分期的簡單摘要,如「第3期」。針對特定疾病的分期測定。


A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.

Short簡單的摘要(特定疾病)。Simple summary (disease specific)
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1, con-1
BindingFor example codes, see ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage

描述病情、問題或診斷分期的代碼(例如:癌症分期)。可參考ConditionStage值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。


Codes describing condition stages (e.g. Cancer stages).

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. Condition.stage.assessment
Definition

分期評估所依據的證據之正式記錄


Reference to a formal record of the evidence on which the staging assessment is based.

Short正式的評估記錄Formal record of assessment
Control0..*
This element is affected by the following invariants: con-1
TypeReference(ClinicalImpression, DiagnosticReport, TW Core Observation Laboratory Result, TW Core Observation Vital Signs, Observation)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. Condition.stage.type
Definition

分期的種類,如病理分期或臨床分期。


The kind of staging, such as pathological or clinical staging.

Short分期的種類Kind of staging
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type

病情、問題或診斷分期種類的代碼(如臨床或病理);可參考ConditionStageType值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。


Codes describing the kind of condition staging (e.g. clinical or pathological).

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. Condition.evidence
Definition

作為病情、問題或診斷驗證狀態基礎的支持證據/臨床表現,如證實或反駁病情、問題或診斷的證據。


Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition.

Short支持的證據Supporting evidence
Comments

證據可以是一個簡單的編碼症狀/臨床表現的清單,或參考檢驗檢查或者正式評估,或者兩者都是。


The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscon-2: evidence SHALL have code or details (code.exists() or detail.exists())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
con-2: evidence SHALL have code or details (code.exists() or detail.exists())
78. Condition.evidence.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。


Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short唯一可識別ID,以供資料項目間相互參照。Unique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
80. Condition.evidence.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。


May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Short擴充的資料項目Additional content defined by implementations
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
82. Condition.evidence.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。
修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。


May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。Extensions that cannot be ignored even if unrecognized
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。


There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互操作性。更多訊息,請參見修飾用的資料項目擴充之定義


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
84. Condition.evidence.code
Definition

導致記錄此病情、問題或診斷的表現或症狀


A manifestation or symptom that led to the recording of this condition.

Short表現/症狀Manifestation/symptom
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..*
This element is affected by the following invariants: ele-1, con-2
BindingFor example codes, see ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom

病情、問題或診斷的表現或症狀之代碼;可參考ManifestationAndSymptomCodes值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。


Codes that describe the manifestation or symptoms of a condition.

TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. Condition.evidence.detail
Definition

其他相關資訊的連接,包括病理報告。


Links to other relevant information, including pathology reports.

Short在其他地方找到的支持資訊Supporting information found elsewhere
Control0..*
This element is affected by the following invariants: con-2
TypeReference(Resource)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. Condition.note
Definition

關於此Condition的附加資訊。這是一個一般的註釋/意見紀錄,用於描述病情、問題或診斷、其診斷和預後。


Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.

Short關於此Condition的附加資訊Additional information about the Condition
Control0..*
TypeAnnotation
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. Condition
Definition

一個臨床病情、問題、診斷或其他事件、情況、或臨床概念,已上升到需要關注的程度。

Short有關病情、問題或診斷的詳細資訊
Control0..*
Is Modifierfalse
Summaryfalse
Invariantscon-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item (clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty())
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists())
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error (verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty())
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Condition.id
Definition

resource的邏輯ID,在resource的URL中使用。一旦指定,這個值永遠不會改變。

Short不重複的ID用以識別儲存在特定FHIR Server中的Condition紀錄,通常又稱為邏輯性ID。
Comments

一個resource使用新增操作(create operation)提交給伺服器時是此resource唯一沒有id的時刻

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. Condition.meta
Definition

關於resource的metadata。這是由基礎建設維護的內容。對內容的改變可能並不總是與resource的版本改變相關。

Short此Condition Resource的metadata
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. Condition.implicitRules
Definition

構建resource時遵循的一系列規則的參照,在處理內容時必須理解這些規則。通常這是IG定義特殊規則及其他profiles的參照。

Short創建此內容所依據的一組規則
Comments

宣告這套規則限制了內容只能被有限的貿易夥伴所理解。這從本質上限制了資料的長期有用性。然而,現有的健康生態體系高度分裂,還沒有準備好以普遍可計算的方式定義、收集和交換資料。只要有可能,實作者和(或)規範編寫者應該避免使用這個資料項目。通常,在使用時,此URL是對實作指引的參照,此指引將這些特殊規則與其他profiles、value sets等一起定義為其敘述的一部分。

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Condition.language
Definition

編寫此resource的基礎語言

Short用以表述Condition Resource內容的語言
Comments

提供語言是為了支援索引和可存取性(通常,文字表述轉語音等服務使用此語言標籤)。html lanuage tag適用於此敘述。resource上的語言標籤可用於指定從resource中的資料所產成的其他表述之語言。不是所有的內容都必須使用此基礎語言。不應該假定Resource.language自動適用於敘述。如果指定語言,它也應該被指定在html中的div元素(關於xml:lang和html lang屬性之間的關係,見HTML5中的規則)。

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages: 人類語言;鼓勵使用CommonLanguages值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。
Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Example<br/><b>Value</b>:zh-TW
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Condition.text
Definition

人可讀的敘述,包含resource的摘要,可用於向人表述resource的內容。敘述不需要對所有的結構化資料進行編碼,但需要包含足夠的細節使人在閱讀敘述時理解「臨床安全性」。resource定義可定義哪些內容應該在敘述中表示,以確保臨床安全。

ShortCondition Resource之內容摘要以供人閱讀
Comments

內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。在某些情況下,resource可能只有文字表述,很少或沒有額外的離散資料(只要滿足所有minOccurs=1的資料項目)。這對於來自舊有系統的資料可能是必要的,在這些系統中,從 「文字表述區塊(text blob) 」獲取訊息,或者文字表述是額外的原始輸入或敘述,而編碼訊息是後來添加的。

Control0..1
TypeNarrative
Is Modifierfalse
Must Supporttrue
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Condition.contained
Definition

這些resource內嵌(contains)的resource不會另外存於任何FHIR伺服器,意即它們無法在任何FHIR伺服器中被找到,也無法有自己獨立的資料異動/交易(transaction)範圍。

Short內嵌的(contained)、行內的Resources
Comments

內嵌(contained)的resource沒有敘述,非內嵌(contained)的resource則 建議應該(SHOULD) 有敘述。在某些情況下,resource可能只有文字表述,很少或沒有額外的離散資料(只要滿足所有minOccurs=1的資料項目)。這對於來自舊有系統的資料可能是必要的,在這些系統中,從 「文字表述區塊(text blob) 」獲取訊息,或者文字表述是額外的原始輸入或敘述,而編碼訊息是後來添加的。

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. Condition.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
16. Condition.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。
修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互操作性。更多訊息,請參見修飾用的資料項目擴充之定義

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
18. Condition.identifier
Definition

由執行者或其他系統指定給此病情、問題或診斷的業務用識別碼,即使此resource作更新及在伺服器之間的傳遞,此識別碼仍保持不變。

Short此病情、問題或診斷的外部識別碼
Comments

這是一個業務識別碼,不是一個resource識別碼(詳見討論)。最好的做法是該識別碼只出現在單個resource實例上,但是業務實務有可能會規定可以在多個resource實例中具有相同識別碼—甚至可能具有不同的resource型例。例如:多個 「Patient(病人)」和 「Person(個人)」resource實例可能共用同一個社會保險號碼。

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Summarytrue
Requirements

允許識別各參與系統所知的此病情、問題或診斷資訊,並在各伺服器之間保持一致的方式。

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Condition.clinicalStatus
Definition

此病情、問題或診斷的臨床狀態

Short概念(Concept)— 參照一個專門術語或只是文字表述
Comments

data type是CodeableConcept,因為clinicalStatus涉及到一些臨床判斷,例如:可能需要比所需的FHIR值集更多的特殊性。例如:SNOMED編碼可能允許更多的特殊性。

Control1..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from ConditionClinicalStatusCodes: 病情、問題或診斷的臨床狀態;應填入ConditionClinicalStatusCodes值集中的其中一個代碼。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. Condition.verificationStatus
Definition

支持此病情、問題或診斷的臨床狀態之驗證狀態

Short概念(Concept)— 參照一個專門術語或只是文字表述
Comments

verificationStatus不是必須的。例如:當病人在急診室出現腹痛時,不可能出現驗證狀態。資料類型是CodeableConcept,因為verificationStatus涉及到一些臨床判斷,因此可能需要比所需的FHIR值集更多的特殊性。例如:SNOMED編碼可能允許更多的特殊性。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from ConditionVerificationStatus: 支持或拒絕病情、問題或診斷的臨床狀態的驗證狀態;應填入ConditionVerificationStatus值集中的其中一個代碼。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Condition.category
Definition

指定此病情、問題或診斷的類別

Short概念(Concept)— 參照一個專門術語或只是文字表述
Comments

這種分類往往具有很強的情境性,在其他情境下可能顯得區分度不高,或沒有什麼用處。

Control1..1
This element is affected by the following invariants: ele-1
BindingUnless not suitable, these codes SHALL be taken from ConditionCategoryCodes: 指定病情、問題或診斷的類別;應填入ConditionCategoryCodes值集中適合的代碼,確定無適合的代碼才可以使用其他值集的代碼來表示。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. Condition.severity
Definition

臨床醫生對病情、問題或診斷嚴重程度的主觀評估

Short病情、問題或診斷的主觀嚴重程度
Comments

如有可能,最好用專門術語對嚴重程度進行編碼。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHOULD be taken from Problem Severity - IPS: 臨床醫生對病情、問題或診斷嚴重程度的主觀評價;鼓勵使用Problem Severity - IPS值集中的代碼,但不強制一定要使用此值集,你也可使用其他值集的代碼或單純以文字表示。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Condition.code
Definition

病情、問題或診斷的識別

Short病情、問題或診斷的識別
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see Condition/Problem/DiagnosisCodes: 病情、問題或診斷的識別;可參考Condition/Problem/DiagnosisCodes值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Requirements

0..1,主要用於說明敘述性resource。

Alternate Namestype
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Condition.code.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
32. Condition.code.extension
Definition

An Extension

ShortExtension
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何汙名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Condition.code.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ url
34. Condition.code.coding
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short由專門術語系統(terminology system)定義的代碼
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..*
This element is affected by the following invariants: ele-1
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Condition.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ $this
36. Condition.code.coding:icd10-cm-2021
Slice Nameicd10-cm-2021
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為臺灣衛生福利部中央健康保險署維護之2021年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from 臺灣2021年中文版ICD-10-CM值集: 病情、問題或診斷的識別;應填入臺灣2021年中文版ICD-10-CM值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. Condition.code.coding:icd10-cm-2014
Slice Nameicd10-cm-2014
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為臺灣衛生福利部中央健康保險署維護之2014年中文版ICD-10-CM代碼,涵蓋範圍相對完整,可免費使用,可優先選用此代碼。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from 臺灣2014年中文版ICD-10-CM值集: 病情、問題或診斷的識別;應填入臺灣2014年中文版ICD-10-CM值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. Condition.code.coding:icd9-cm-2001
Slice Nameicd9-cm-2001
Definition

由專門術語系統(terminology system)所定義之代碼的參照

Short由專門術語系統(terminology system)定義的代碼
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,例如:SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from 臺灣2001年中文版ICD-9-CM值集
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許代碼系統中的替代編碼,以及翻譯到其他編碼系統。

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. Condition.code.coding:absentOrUnknownProblem
Slice NameabsentOrUnknownProblem
Definition

表示「absent problem」或「problems unknown」的代碼

Short不存在的問題或未知問題的代碼
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from Absent or Unknown Problems - IPS: 應填入Absent or Unknown Problems - IPS值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. Condition.code.coding:sct
Slice Namesct
Definition

由專門術語系統(terminology system)所定義之代碼的參照。

Short此為SNOMED CT診斷代碼,若機構已有購買相關授權,亦可使用。
Comments

代碼可以在列舉清單(enumerations)或代碼清單(code lists)中非常隨意地定義,直至有非常正式的定義,如SNOMED CT—更多資訊見HL7 v3核心原則(Core Principles )。編碼的排序是未定義的因而 必須沒有(SHALL NOT) 被用來推斷意義。一般來說,最多只有一個編碼值(coding values)會被標記為UserSelected = true。

Control0..1
This element is affected by the following invariants: ele-1
BindingThe codes SHALL be taken from SNOMED CT診斷代碼值集: 應填入SNOMED CT診斷代碼值集值集中的其中一個代碼。
TypeCoding(TW Coding)
Is Modifierfalse
Must Supporttrue
Requirements

允許使用者在不知道識別碼系統的情況下利用識別碼

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. Condition.code.text
Definition

輸入資料的使用者所見/所選/所說的人類可讀文字表述,和(或)其代表使用者的預期含義。

Short概念的文字表示法
Comments

很多時候,此文字表述與其中一個代碼的顯示名稱相同。

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

專門術語中的代碼並不總是能捕捉人類使用的細微差別的正確意義,或者根本就沒有合適的代碼;這些情況下,文字表述被用來捕捉來源的全部意義。

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. Condition.bodySite
Definition

此病情、問題或診斷表現出來的解剖位置

Short如果相關請填寫解剖位置
Comments

只有在Condition.code中找到的代碼未隱含此資料項目概念時才使用。如果使用案例(use-case)要求將BodySite作為一個單獨的resource來處理(例如:識別和追踪),那麼就使用標準的資料項目擴充方式來擴充bodySite。可以是一個摘要代碼,也可以是對一個非常精確位置定義的參照,或者兩者都是。

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see SNOMEDCTBodyStructures: 描述解剖位置的代碼。可包括側面;可參考SNOMEDCTBodyStructures值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Condition.subject
Definition

表示與此病情、問題或診斷紀錄相關的病人或實體集合(Group resource)

Short誰有此病情、問題或診斷?
Control1..1
TypeReference(TW Core Patient, Group)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Requirements

實體集合(Group resource)通常用於獸醫或公共衛生的案例

Alternate Namespatient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Condition.encounter
Definition

此病情、問題或診斷記載在哪次的「就醫(Encounter)」紀錄或者與此病情、問題或診斷紀錄密切相關的「就醫(Encounter)」紀錄

Short作為病情、問題或診斷紀錄的一部分的就醫(Encounter)紀錄
Comments

通常是此病情、問題或診斷發生的就醫事件,雖然有些活動可能在就醫結束之前或之後開始,但仍與就醫事件的情境有關。這筆紀錄表明與此病情、問題或診斷紀錄相關的就醫事件(Encounter)。「新的」診斷的情況下,反映病情、問題或診斷的持續/修訂資訊可能與首次就醫所知道的病情、問題或診斷不同。

Control0..1
TypeReference(TW Core Encounter)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Condition.onset[x]
Definition

醫師認為此病情、問題或診斷之推估或實際發生時間或日期時間等

Short估計的或實際的日期、日期—時間或年齡。
Comments

onsetAge通常是指病人說明病情何時開始發生的年齡

Control0..1
TypeChoice of: dateTime, Age, Period, Range, string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesdateTime
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Condition.abatement[x]
Definition

病情、問題或診斷緩解或開始緩解的日期或估計日期。因為與「緩解(remissio)」或 「解決(resolution)」相關的許多過多含義—病情、問題或診斷不會真正解決,但它們可以緩解,所以稱為「緩解 (abatement)」,

Short何時解決/緩解
Comments

解決(resolution)和緩解(remission)之間沒有明確的區別,因為在許多情況下,兩者的區別並不明顯。當病人說明病情、問題或診斷緩解的年齡時,一般使用onsetAge。如果沒有abatement這個資料項目,就不知道狀況是否已經解決或緩解;應用程式和使用者一般應假定病情、問題或診斷仍存在。當abatementString存在時,它意味著病情、問題或診斷已緩解。

Control0..1
This element is affected by the following invariants: con-4
TypeChoice of: dateTime, Age, Period, Range, string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesdateTime
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. Condition.recordedDate
Definition

recordedDate表述此Condition記錄何時於系統中建立,這通常是系統產生的日期。

Short記錄的日期
Control0..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. Condition.recorder
Definition

記錄病情、問題或診斷內容並對其內容負責的個人

Short誰記錄此病情、問題或診斷
Control0..1
TypeReference(TW Core Practitioner, PractitionerRole, TW Core Patient, RelatedPerson)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. Condition.asserter
Definition

提出此病情、問題或診斷說明的人

Short聲稱有此病情、問題或診斷的人
Control0..1
TypeReference(TW Core Practitioner, PractitionerRole, TW Core Patient, RelatedPerson)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. Condition.stage
Definition

病情、問題或診斷的臨床分期或分級,可能包括正式的嚴重程度評估。

Short分期(stage)/分級(grade),通常是正式的評估。
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscon-1: Stage SHALL have summary or assessment (summary.exists() or assessment.exists())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
66. Condition.stage.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
68. Condition.stage.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
70. Condition.stage.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。
修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互操作性。更多訊息,請參見修飾用的資料項目擴充之定義

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
72. Condition.stage.summary
Definition

對分期的簡單摘要,如「第3期」。針對特定疾病的分期測定。

Short簡單的摘要(特定疾病)。
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ConditionStage: 描述病情、問題或診斷分期的代碼(例如:癌症分期)。可參考ConditionStage值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. Condition.stage.assessment
Definition

分期評估所依據的證據之正式記錄

Short正式的評估記錄
Control0..*
This element is affected by the following invariants: con-1
TypeReference(ClinicalImpression, DiagnosticReport, TW Core Observation Laboratory Result, TW Core Observation Vital Signs)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. Condition.stage.type
Definition

分期的種類,如病理分期或臨床分期。

Short分期的種類
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see ConditionStageType: 病情、問題或診斷分期種類的代碼(如臨床或病理);可參考ConditionStageType值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
78. Condition.evidence
Definition

作為病情、問題或診斷驗證狀態基礎的支持證據/臨床表現,如證實或反駁病情、問題或診斷的證據。

Short支持的證據
Comments

證據可以是一個簡單的編碼症狀/臨床表現的清單,或參考檢驗檢查或者正式評估,或者兩者都是。

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscon-2: evidence SHALL have code or details (code.exists() or detail.exists())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
80. Condition.evidence.id
Definition

resource中資料項目的唯一ID(用於內部參照)。這可以是任何不含空格的字串。

Short唯一可識別ID,以供資料項目間相互參照。
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
82. Condition.evidence.extension
Definition

可用於表示不屬於此資料項目基本定義的附加資訊。為了擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。

Short擴充的資料項目
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
84. Condition.evidence.modifierExtension
Definition

可以用來表示不屬於資料項目的基本定義的附加資訊,並且修改對它所內嵌(contained)的資料項目的理解和(或)對包含資料項目之後續使用的理解。通常,修飾用的資料項目提供否定或限定。為了使擴充的使用安全和可管理,對擴充的定義和使用有一套嚴格的管理。儘管任何實作者都可以定義一個擴充,但作為擴充定義的一部分,有一套要求 必須(SHALL) 滿足。處理resource的應用程式被要求檢查修飾用的擴充資料項目。
修飾用的擴充資料項目 必須沒有(SHALL NOT) 改變resource或DomainResource上任何資料項目的含義(包括不能改變modifierExtension本身的含義)。

Short此擴充的資料項目可能會完全修正或改變其他資料項目的意涵,需特別留意。
Comments

無論使用或定義擴充的機構或管轄區,任何應用程式、專案或標準使用擴充都不背負任何污名(stigma)。使用擴充是允許FHIR規範為每個人保留一個核心的簡易性。

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

修飾用的資料項目擴充將不能安全地忽略的擴充與絕大多數可以安全地忽略的擴充明確區分開來。透過消除禁止實作者擴充存在的需求來促進可互操作性。更多訊息,請參見修飾用的資料項目擴充之定義

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
86. Condition.evidence.code
Definition

導致記錄此病情、問題或診斷的表現或症狀

Short表現/症狀
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control0..*
This element is affected by the following invariants: ele-1
BindingFor example codes, see ManifestationAndSymptomCodes: 病情、問題或診斷的表現或症狀之代碼;可參考ManifestationAndSymptomCodes值集,但此值集只是針對這個欄位的一個可能值的範例,不預期也不鼓勵使用者一定要使用此值集的代碼。
TypeCodeableConcept(TW CodeableConcept)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. Condition.evidence.detail
Definition

其他相關資訊的連接,包括病理報告。

Short在其他地方找到的支持資訊
Control0..*
This element is affected by the following invariants: con-2
TypeReference(Resource)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. Condition.note
Definition

關於此Condition的附加資訊。這是一個一般的註釋/意見紀錄,用於描述病情、問題或診斷、其診斷和預後。

Short關於此Condition的附加資訊
Control0..*
TypeAnnotation
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))